Minimally Invasive Brain Surgery — Cost, Top Hospitals & Success Rates | MyMedicPlus

Minimally invasive brain surgery (MIBS) encompasses a rapidly expanding set of neurosurgical techniques designed to achieve maximal surgical objectives — tumour resection, lesion ablation, hydrocephalus treatment, epilepsy surgery — while minimising trauma to surrounding normal brain tissue, cranial bone, and scalp. The unifying principle across all MIBS approaches is: achieve the surgical goal through the smallest possible anatomically safe corridor.

Traditional open craniotomy involves large bone flaps (10–15 cm or more), extensive brain retraction to create exposure, and long recovery periods. Modern minimally invasive techniques instead exploit naturally occurring anatomical corridors (nasal passages, Sylvian fissures, transtentorial pathways) or create narrow surgical tubes through otherwise intact tissue. The result is less blood loss, shorter hospital stays, faster functional recovery, and in many cases improved patient outcomes.

Enabling Technologies

MIBS is made possible by several converging technological developments:

• High-definition endoscopes: 4K-resolution rigid and flexible endoscopes with angled optics (0°, 30°, 45°, 70°) allow visualisation around corners and deep in narrow anatomical spaces impossible to visualise with the direct-line-of-sight of the operating microscope
• Frameless stereotactic neuronavigation: Systems such as BrainLab Kick and Medtronic StealthStation use pre-operative MRI/CT data merged with intraoperative tracking to provide real-time 3D surgical navigation — allowing the surgeon to know the precise anatomical location of instruments at all times, without the discomfort of a stereotactic frame
• Tubular retractor systems: Cylindrical ports (METRx, Vycor ViewSite Brain Access System) dilate rather than cut brain tissue, creating a working channel that preserves the architecture of intervening tissue
• Intraoperative MRI (iMRI) and CT: Available in specialised 'MR-suite' operating rooms; allows real-time confirmation of resection extent or instrument positioning without moving the patient from the OR table
• Fluorescence-guided surgery (5-ALA): Oral 5-aminolevulinic acid causes malignant brain tumour cells to fluoresce pink-red under specific light wavelengths, enhancing the surgeon's ability to identify and remove tumour margins

MIBS techniques address a broad spectrum of intracranial pathologies:

Brain Tumours

• Pituitary adenomas: The most common indication for endoscopic skull base surgery. Endoscopic endonasal approach (EEA) is now the standard of care for most pituitary tumours worldwide, having largely replaced open transcranial approaches.
• Craniopharyngiomas: Suprasellar tumours arising from remnants of Rathke's pouch. Extended EEA allows access from below to tumours involving the third ventricle floor without frontal lobe retraction.
• Meningiomas: Benign dural-based tumours that may be resected via keyhole craniotomy when located in accessible convexity, falcine, or skull base positions.
• Gliomas (high and low grade): When in or near eloquent cortex, tubular retractor approaches or awake craniotomy with functional mapping enable aggressive yet safe resection. LITT is increasingly used for deep-seated or recurrent gliomas where open resection carries unacceptable neurological risk.
• Acoustic neuromas (vestibular schwannomas): Retrosigmoid keyhole approach preserves hearing and facial nerve function; the posterior fossa is accessed through a 3–4 cm incision behind the ear.
• Clival lesions (chordomas, chondrosarcomas): Endoscopic endonasal transpterygoid and transclival approaches now allow resection of these deep skull base tumours without facial incisions or brain retraction.

Vascular Conditions

• Intracranial aneurysms: Small keyhole craniotomies can provide adequate exposure for microsurgical clipping of anterior circulation aneurysms (supraorbital eyebrow approach for A-comm and MCA aneurysms, retrosigmoid approach for posterior fossa aneurysms)
• Cavernous malformations: Deep-seated cavernomas approached through METRx tubular retractors with neuronavigation; avoids the extensive cortical exposure of traditional open approaches

Hydrocephalus

• Endoscopic third ventriculostomy (ETV): Neuroendoscopic procedure that creates a communication between the third ventricle and the subarachnoid space, bypassing obstructive hydrocephalus. Avoids permanent ventriculoperitoneal (VP) shunt placement and its associated long-term hardware complications. Success rate for obstructive hydrocephalus: 60–80% in adults.
• Endoscopic choroid plexus coagulation (ETV+CPC): Combined with ETV in infants for communicating hydrocephalus; higher success rates than ETV alone in young children.

Epilepsy Surgery

• LITT (laser interstitial thermal therapy): Increasingly used for mesial temporal sclerosis (hippocampal ablation), hypothalamic hamartoma, focal cortical dysplasia, and radiation necrosis causing refractory epilepsy. MRI-guided laser ablation through a 3.2 mm skull bolt — truly minimally invasive epilepsy surgery.
• Stereotactic depth electrode implantation (SEEG): Minimally invasive diagnostic technique — multiple thin electrode wires passed through twist-drill burr holes to map epileptogenic networks before ablative surgery.

Movement Disorders and Functional Conditions

• MR-guided focused ultrasound (MRgFUS): Non-invasive thalamotomy for essential tremor and Parkinson's tremor — completely incisionless, performed through the intact skull using 1,024 focused ultrasound beams converged on the VIM nucleus of the thalamus. FDA-cleared for essential tremor (2016) and Parkinson's tremor (2018).
• Deep brain stimulation (DBS) electrode placement: Stereotactic or intraoperative MRI-guided placement of DBS leads through small burr holes for Parkinson's, essential tremor, dystonia, and OCD.

Not all brain lesions or patients are suitable for minimally invasive approaches. The decision requires careful assessment by an experienced neurosurgical team, often in a multidisciplinary tumour board or functional neurosurgery conference:

Factors Favouring Minimally Invasive Approach

• Lesion location in a region accessible through a natural anatomical corridor (pituitary/sella — endonasal; posterior fossa — retrosigmoid; convexity — keyhole craniotomy)
• Lesion size appropriate for the approach — very large tumours requiring extensive exposure may still require traditional craniotomy
• Clear surgical anatomy on pre-operative high-resolution MRI (1.5T or 3T, with gadolinium contrast, plus functional MRI for eloquent cortex mapping)
• Patient fitness for the planned anaesthetic type (general vs monitored anaesthesia care in awake procedures)
• Absence of prior surgery or radiation that has distorted surgical planes

Pre-Operative Workup

• MRI brain with and without contrast: Standard 1.5T minimum; 3T preferred. Specialised sequences: DWI, SWI (for blood products), MR spectroscopy (tumour vs radiation necrosis), DTI/tractography (white matter tract mapping)
• Functional MRI (fMRI): Maps language (Broca's/Wernicke's areas), motor cortex, and memory areas pre-operatively — essential for planning surgery near eloquent cortex
• MR tractography (DTI): Maps white matter tracts (corticospinal tract, arcuate fasciculus) in relation to the lesion — guides safe resection corridors
• CT head: For bone anatomy, particularly in skull base surgery and for neuronavigation registration
• Angiography (CTA/MRA or DSA): For vascular lesions or tumours with significant vascular involvement
• Endocrinological assessment: Mandatory before pituitary surgery — formal endocrine testing to quantify hormone excess (acromegaly, Cushing's, prolactinoma) and hypopituitarism
• Neuropsychological assessment: Baseline cognitive and language testing before any procedure near eloquent cortex, including before awake craniotomy
• Ophthalmological assessment: Formal Humphrey visual field testing and optical coherence tomography before and after pituitary/suprasellar tumour surgery

Each technique represents a distinct approach to minimising the surgical footprint while achieving the intended goal:

1. Keyhole Craniotomy

Keyhole (or 'lock-hole') craniotomies use a small bone window — typically 2–4 cm diameter — positioned precisely to provide the minimum necessary exposure for the target lesion. Navigation is essential. Principal keyhole approaches include:

• Supraorbital (eyebrow) approach: 3–4 cm incision within the eyebrow; a 2–3 cm bone window through the frontal skull above the orbit. Access to: anterior skull base, suprasellar region, anterior communicating artery aneurysms, frontal tumours, Sylvian fissure lesions. Leaves a scar hidden in the eyebrow with minimal cosmetic impact.
• Retrosigmoid (suboccipital) approach: 3–4 cm incision behind the ear; 2–3 cm posterior fossa craniotomy. Access to: acoustic neuromas (vestibular schwannomas), posterior fossa meningiomas, posterior circulation aneurysms (basilar, PICA), microvascular decompression for trigeminal neuralgia or hemifacial spasm.
• Pterional (mini-pterional) approach: Reduced-size classic temporal craniotomy; access to Sylvian fissure, MCA aneurysms, sphenoid wing meningiomas.
• Transpetrosal approach: Access to the petroclival region (clivus, petroclival meningiomas) through the mastoid; may be combined with endoscopy.

2. Tubular Retractor Systems

Instead of retracting and holding brain tissue apart with static retractor blades (which cause ischaemia and oedema), tubular systems create a cylindrical working channel through the brain by dilation:

• METRx system (Medtronic): Originally designed for spine surgery; adapted for deep brain lesions. Progressive dilation through a small cortical incision; provides an 18–26 mm working tube through which an operating microscope or endoscope is used.
• Vycor ViewSite Brain Access System: Clear, transparent retractor tube allowing panoramic visualisation around the tube perimeter; available in multiple diameters (14–30 mm).
• Applications: deep-seated tumours (thalamic glioma, deep metastases), cavernous malformations, intraventricular tumours, and intracerebral haematoma evacuation. Brain retraction pressure is minimised, reducing post-operative oedema and neurological deficits.

3. Endoscopic Endonasal Approach (EEA)

The gold standard for pituitary adenomas and extended skull base lesions. Performed through the nostrils — no lip, gum, or facial incision. A nasal speculum or nasoscope provides initial access; the sphenoid sinus is opened to reach the sella turcica (pituitary fossa). An HD endoscope (0° and 30°) provides far superior illumination and magnification deep in the skull base compared to the operating microscope through a transcranial approach.

• Standard EEA (transsphenoidal): For pituitary adenomas, Cushing's disease (ACTH-secreting microadenomas), acromegaly (GH-secreting tumours), prolactinomas, non-functioning macroadenomas with chiasmal compression. Remission rates comparable to transcranial surgery with faster recovery (discharge in 2–3 days vs 5–7 days).
• Extended EEA (transplanum, transclival, transpterygoid): By removing additional bone (planum sphenoidale, clivus, pterygoid plates), access is extended to craniopharyngiomas, clival chordomas, and petroclival meningiomas. Skull base repair with vascularised nasoseptal flap (Hadad-Bassagasteguy flap) is essential to prevent CSF leak.

4. Awake Craniotomy with Intraoperative Brain Mapping

For tumours within or immediately adjacent to eloquent cortex (primary motor cortex, Broca's and Wernicke's language areas), awake craniotomy with direct electrical cortical stimulation mapping is the gold standard for maximising tumour resection while preserving neurological function.

• Procedure: Patient sedated for initial craniotomy opening (asleep-awake-asleep protocol); awakened during the cortical mapping and tumour resection phase. A nurse or speech-language pathologist conducts continuous speech, language, and/or motor tasks during stimulation and resection.
• Direct cortical stimulation: Low-intensity bipolar electrical current applied to cortical and subcortical sites. Stimulation causing speech arrest, naming errors, or motor responses identifies 'eloquent' areas that must be preserved.
• Outcome evidence: Meta-analyses demonstrate higher rates of gross total resection, lower post-operative permanent neurological deficits (6–8% vs 15–20% for resection under general anaesthesia), and no increase in intraoperative complications compared to asleep craniotomy for equivalent lesions.
• Contraindications: significant patient anxiety, inability to cooperate, seizure disorder with frequent intraoperative events, language or cognitive deficits preventing meaningful mapping.

5. Laser Interstitial Thermal Therapy (LITT)

LITT delivers precisely controlled laser energy through a 1.6–3.3 mm laser probe introduced stereotactically through a single burr hole, ablating the target tissue with heat while real-time MRI thermometry monitors temperature and the predicted ablation volume.

• Systems: Visualase (Medtronic) and NeuroBlate (Monteris Medical) are the two FDA-cleared platforms
• Procedure: MRI-guided stereotactic placement of the laser catheter under general anaesthesia; patient then moved to MRI suite for thermal ablation with real-time temperature mapping. Total procedure time 3–6 hours. Hospital stay 1–2 days.
• Applications: Mesial temporal lobe epilepsy (MTE/hippocampal sclerosis) — comparable seizure freedom rates to open temporal lobectomy in select patients with faster recovery; hypothalamic hamartoma; deep-seated gliomas (recurrent GBM); radiation necrosis (differentiated from recurrent tumour by MR spectroscopy); deep-seated metastases not amenable to open surgery.
• Limitations: Cannot provide tissue for histological diagnosis (no specimen); thermal spread must be carefully controlled near critical structures (optic tracts, thalamus, brainstem); requires a specialised iMRI-equipped neurosurgical unit.

6. MR-Guided Focused Ultrasound (MRgFUS)

Completely non-invasive — no incision, no skull opening, no anaesthesia beyond light sedation. The ExAblate Neuro system (InSightec) uses 1,024 transducer elements to focus ultrasound beams through the intact skull, converging to create a thermal lesion 2–3 mm in diameter at the target. Real-time MRI monitoring confirms location and temperature.

• FDA-cleared for: essential tremor (VIM thalamotomy, 2016) and Parkinson's disease tremor-dominant (2018)
• Under investigation: dyskinesia, OCD, major depression, neuropathic pain, Alzheimer's disease (blood-brain barrier opening)
• Limitation: skull density ratio affects ultrasound penetration — patients with very dense or heterogeneous skull bone (CT-assessed skull density ratio <0.4) may have suboptimal heating

7. Endoscopic Third Ventriculostomy (ETV)

A rigid neuroendoscope is introduced through a single frontal burr hole, advanced through the lateral ventricle and foramen of Monro into the third ventricle. A perforation is created in the floor of the third ventricle (between the mamillary bodies and infundibular recess) using monopolar coagulation and balloon dilation, establishing CSF flow directly into the prepontine cistern. Eliminates the need for a shunt in obstructive hydrocephalus.

The evidence base supporting minimally invasive neurosurgical techniques has matured substantially over the past two decades:

• Smaller cranial opening: Keyhole approaches (2–4 cm) vs traditional craniotomies (10–15 cm) — significantly less bone removal, blood loss, and scalp disruption
• Reduced brain retraction: Tubular systems and natural corridor approaches eliminate the prolonged static retraction associated with post-operative cerebral oedema, contusion, and neurological deficits
• Shorter hospital stay: Keyhole craniotomy: 2–3 days; EEA pituitary surgery: 2–3 days; LITT: 1–2 days — compared to 7–14 days for major open craniotomy
• Faster functional recovery: Patients undergoing EEA for pituitary adenomas return to work in 1–2 weeks; open transcranial approaches require 4–8 weeks recovery
• Superior deep visualisation: Endoscopes placed directly into cavities provide HD panoramic views of areas inaccessible or poorly visualised through the operating microscope from a distance
• Preserved function (awake craniotomy): Direct cortical mapping enables resection of tumours previously considered inoperable due to proximity to speech or motor cortex — expanding the surgical frontier into eloquent brain
• Less post-operative pain: Smaller incisions and less muscle dissection translate to lower post-operative analgesic requirements
• Reduced CSF disruption: Targeted approaches with less brain retraction reduce post-operative CSF leak and meningitis risk
• Comparable oncological outcomes: Multiple meta-analyses and systematic reviews demonstrate equivalent or superior gross total resection rates for key tumour types with keyhole and endoscopic approaches compared to traditional open surgery in appropriately selected patients

Minimally invasive neurosurgery reduces but does not eliminate surgical risk. The brain is uniquely vulnerable — even minor trauma carries neurological consequence.

General Neurosurgical Risks

• Intracranial haemorrhage: Intraoperative (arterial or venous bleeding) or post-operative haematoma. Most feared complication; managed by immediate return to OR. Risk is generally lower with minimally invasive approaches due to less tissue disruption.
• Neurological deficit: Temporary or permanent weakness, speech difficulty, visual field loss, or cognitive change depending on surgical location. Minimised but not eliminated by MIBS techniques. Awake craniotomy provides direct intraoperative feedback to prevent permanent deficits.
• Infection: Meningitis, brain abscess, wound infection. Prophylactic antibiotics standard; risk lower with smaller wounds.
• CSF leak: Particularly relevant in skull base surgery; requires watertight closure and vascularised flap repair in EEA. Unrecognised CSF leak risks ascending meningitis.

Technique-Specific Risks

• Endoscopic endonasal approach: Epistaxis, sinusitis, nasal crusting (6–12 weeks); CSF rhinorrhoea (2–5% in extended approaches, requiring repair); injury to carotid arteries or cavernous sinus (rare but catastrophic); diabetes insipidus (transient 20–30%, permanent 2–5%) after pituitary surgery; anterior pituitary hormone deficiency; visual deterioration (rare if vision preserved pre-operatively); meningitis (1–2%)
• Awake craniotomy: Intraoperative seizure (5–10%); patient anxiety or inability to cooperate requiring conversion to general anaesthesia; vascular injury if patient moves unexpectedly; post-operative temporary speech or motor deficits (10–20%, resolving in 1–3 months)
• LITT: Oedema around ablation zone causing temporary neurological deficit; thermal injury to adjacent critical structures (vision, motor tracts) if margins not respected; limited biopsy tissue; hardware infection (burr hole site); incomplete ablation requiring repeat procedure
• ETV: Failure rate 20–40% (conversion to shunt required); injury to basilar artery or perforating vessels on the third ventricle floor; hypothalamic injury (hyperphagia, thermoregulatory dysfunction); early patency then late closure causing recurrent hydrocephalus

Technical Limitations

• MIBS requires specialised training, equipment, and experience — outcomes are strongly surgeon- and centre-volume-dependent
• Some tumours (very large meningiomas, extensive glioblastomas with multiple lobe involvement) still require traditional open approaches
• Anatomical variations may preclude planned approaches and require intraoperative conversion to open craniotomy
• MIBS centres require significant capital investment in navigation systems, endoscope towers, LITT equipment, and/or iMRI facilities

Post-operative management depends on the procedure performed, pathology treated, and any neurological deficits present:

Immediate Post-Operative Period (Hours to Days)

• Neurological observation: hourly GCS, pupils, limb power assessments for 24–48 hours post-operatively
• Post-operative CT or MRI within 24–48 hours to confirm resection extent and exclude haematoma or infarct
• Pain management: typically managed with regular paracetamol and codeine; opioids reserved for breakthrough pain; NSAIDs generally avoided (bleeding risk)
• Anti-epileptic prophylaxis: 7–10 days for supratentorial craniotomies (evidence for longer-term prophylaxis only in patients with pre-existing seizures)
• Dexamethasone: perioperative steroid cover to reduce brain oedema around tumour; tapered over 5–10 days

Neurological Rehabilitation

• Speech therapy: Essential post-operatively for patients with language or swallowing difficulties following eloquent cortex surgery or skull base procedures
• Physiotherapy: Mobilisation, gait training, upper and lower limb rehabilitation for motor deficits
• Occupational therapy: Return to activities of daily living, cognitive rehabilitation for executive function or memory difficulties
• Neuropsychological support: Post-operative cognitive assessment and rehabilitation strategies for patients with cognitive changes

Tumour Follow-Up Imaging

• High-grade glioma (GBM): MRI brain at 24–48 hours (immediate post-op), then at 1 month, 3 months, then every 2–3 months during adjuvant chemoradiotherapy and on standard Stupp protocol follow-up
• Low-grade glioma: MRI at 3 months post-operatively, then every 6 months
• Pituitary adenoma: MRI at 3 months (to assess residual/recurrence and confirm decompression), then annually. Endocrinological assessment at 1 and 6 weeks (cortisol, ACTH axis, thyroid axis) and at 3 months
• Meningioma: MRI at 3 months, then annual imaging for 5 years; longer surveillance for WHO grade II/III
• Acoustic neuroma (VS): Audiological and vestibular assessment 6 weeks post-op; MRI at 3 and 12 months, then annually
• ETV for hydrocephalus: MRI at 3 months to confirm stoma patency; urgent review if headache and vomiting recur (stoma closure)

Endocrine Follow-Up After Pituitary Surgery

All patients undergoing pituitary surgery require structured endocrinological follow-up including: morning serum cortisol at day 3 (to assess surgical cure of Cushing's or persistent cortisol deficiency requiring hydrocortisone replacement), post-discharge thyroid and gonadal axis assessment at 6 weeks, and formal dynamic pituitary function tests at 3 months. Diabetes insipidus management with desmopressin (DDAVP) when confirmed; many transient DI cases resolve within days to weeks.

Minimally invasive neurosurgical procedures require expensive specialised equipment, highly trained surgical teams, and advanced imaging facilities — making cost and access significant considerations for international patients:

Procedure-Specific Costs (Approximate)

• Endoscopic pituitary surgery (EEA): USD 15,000–35,000 in the US; USD 6,000–15,000 in India/Thailand at JCI-accredited centres
• Keyhole craniotomy (tumour resection): USD 25,000–60,000 in the US depending on tumour complexity; USD 8,000–20,000 in India
• Awake craniotomy (eloquent cortex tumour): USD 35,000–70,000 in the US (higher due to neurophysiology and speech therapy teams); USD 10,000–25,000 in India and Thailand
• LITT (laser ablation): USD 40,000–80,000 in the US (high equipment cost — laser disposable kit alone costs ~USD 15,000–20,000); limited availability outside the US and select European centres; USD 15,000–30,000 where available internationally
• MRgFUS thalamotomy: USD 20,000–30,000 in the US; USD 8,000–15,000 in South Korea, Israel, and select European centres; limited availability in developing markets
• Endoscopic third ventriculostomy (ETV): USD 10,000–25,000 in the US; USD 3,000–8,000 in India

Key Cost Components

• Surgeon fee (neurosurgeon ± skull base/endoscopy specialist)
• Neurophysiology monitoring team (SSEP, MEP intraoperative monitoring)
• Neuronavigation and imaging (iMRI adds USD 5,000–15,000 to facility cost)
• Equipment disposables (endoscope sheaths, laser fibres, tubular retractor sets)
• Anaesthesia and neurointensive care unit (NICU) stay
• Post-operative rehabilitation (physiotherapy, speech therapy)
• Adjuvant oncological treatment (radiotherapy, chemotherapy billed separately)

Leading International MIBS Centres

Specialised minimally invasive neurosurgery is concentrated in major academic medical centres. Leading destinations for medical tourism in neurosurgery include:

• India: AIIMS New Delhi, Fortis Hospital, Apollo Hospitals, Manipal Hospitals — internationally trained neurosurgeons, competitive costs, growing reputation for complex skull base and MIBS procedures
• Thailand: Bumrungrad International Hospital, Samitivej Hospital Bangkok — JCI-accredited, strong international patient services
• Singapore: National Neuroscience Institute at Singapore General Hospital, Gleneagles — tertiary neuroscience centre with full MIBS capability
• Germany, Switzerland: University hospitals with cutting-edge iMRI and LITT capability

Patients evaluating international neurosurgical care should verify: neurosurgeon subspecialty training (skull base, functional, or neuro-oncology fellowship), centre case volume for the specific procedure, availability of iMRI or intraoperative monitoring, and post-operative oncology infrastructure for adjuvant treatment.

Minimally invasive surgery exists within a broader treatment landscape that includes radiation, medical management, and watchful waiting — the optimal approach varies by pathology:

Stereotactic Radiosurgery (SRS)

Delivers highly focused radiation in one to five sessions to a precisely defined intracranial target. No incision, no anaesthesia required (beyond positioning frame). Platforms include:

• Gamma Knife (Leksell system): 192–201 cobalt-60 sources; gold standard for brain metastases (tumours <3 cm), acoustic neuromas (small-medium), meningiomas (WHO grade I), trigeminal neuralgia, AVMs
• CyberKnife: Linac-based robotic system; frameless (can fractionate over 3–5 sessions); used for skull base and spine lesions, larger tumours not amenable to single-fraction SRS
• Proton therapy: Charged particle radiation with Bragg peak physics — deposits maximum dose at depth with minimal exit dose. Preferred for: skull base chordomas and chondrosarcomas, paediatric brain tumours, tumours adjacent to critical structures (optic nerves, brainstem)

Watchful Waiting

Appropriate for: small (<2 cm), incidentally discovered, slow-growing benign tumours in elderly patients or those with significant comorbidities — particularly vestibular schwannomas, small meningiomas, and pituitary microadenomas with no hormonal excess or chiasmal compression. Serial MRI imaging every 6–12 months monitors for growth, with intervention triggered by documented progression or symptom onset.

Medical Management

• Prolactinomas: First-line treatment is dopamine agonists (cabergoline, bromocriptine) — normalise prolactin, shrink tumours in >80% of cases. Surgery reserved for cabergoline-resistant cases or very large tumours with acute visual threat.
• GLP-1 analogues / Somatostatin analogues (acromegaly): Octreotide, lanreotide, or pasireotide used pre-operatively to reduce tumour volume and improve surgical outcomes, or as primary/adjuvant treatment in patients with post-operative residual disease
• Bevacizumab (Avastin): Anti-VEGF agent used for recurrent glioblastoma and radiation necrosis — reduces oedema and radiological tumour contrast enhancement (though overall survival benefit remains debated)
• Temozolomide (Stupp protocol): Standard adjuvant chemotherapy for glioblastoma following surgical resection; administered concurrently with radiotherapy then for 6 adjuvant cycles

Traditional Open Craniotomy

Remains the appropriate choice for: very large tumours requiring extensive exposure, lesions with complex vascular involvement requiring prolonged microscopic dissection, cases where the MIBS approach failed and open conversion was needed, and situations where trained MIBS expertise is not locally available. The evolution of neurosurgery has not made open craniotomy obsolete — it has defined more precisely when it is and is not necessary.